PHYSIOTHERAPY THEORY AND PRACTICE

2016, VOL. 32, NO. 5, 385–395

http://dx.doi.org/10.1080/09593985.2016.1194652

PERSPECTIVE

The clinical application of teaching people about pain

Adriaan Louw, PT, PhDa, Kory Zimney, PT, DPTb, Christine O’Hotto, PT, DPTc, and Sandra Hilton, PT, DPTd
a
International Spine and Pain Institute, Story City, IA, USA; bDepartment of Physical Therapy, School of Health Sciences, University of South
Dakota, Vermillion, SD, USA; cPhysical Therapy Department, TRIA Orthopaedic Center, Bloomington, MN, USA; dEntropy Physiotherapy and
Wellness, Chicago, IL, USA

ABSTRACT ARTICLE HISTORY

Teaching people about the neurobiology and neurophysiology of their pain experience has a Received 12 November 2015
therapeutic effect and has been referred to as pain neuroscience education (PNE). Various high- Revised 19 December 2015
quality randomized controlled trials and systematic reviews have shown increasing efficacy of PNE Accepted 5 February 2016
decreasing pain, disability, pain catastrophization, movement restrictions, and healthcare utilization. KEYWORDS
Research studies, however, by virtue of their design, are very controlled environments and, there- Application; clinical;
fore, in contrast to the ever-increasing evidence for PNE, little is known about the clinical application education; neuroscience;
of this emerging therapy. In contrast, case studies, case series, and expert opinion and perspectives pain; therapeutic
by authorities in the world of pain science provide clinicians with a glimpse into potential “real”
clinical application of PNE in the face of the ever-increasing chronic pain epidemic. By taking the
material from the randomized controlled trials, systematic reviews, case series, case studies, and
expert opinion, this article aims to provide a proposed layout of the clinical application of PNE. The
article systematically discusses key elements of PNE including examination, educational content,
and delivery methods, merging of PNE with movement, goal setting, and progression. This per-
spectives article concludes with a call for research into the clinical application of PNE.

Introduction educational models often fail (Butler and Moseley, 2003;

Louw, Diener, Butler, and Puentedura, 2013; Louw,
Pain is a normal human experience, and without the
Puentedura, Diener, and Peoples, 2015a; Moseley,
ability to experience pain, people would not survive
2007a). People in pain are interested in learning more
(Gifford, 2014; Moseley, 2007a). Living in pain, however,
about pain, not necessarily anatomy, biomechanics, and
is not normal (Butler and Moseley, 2003; Wall and
pathoanatomy (Louw et al, 2009).
Melzack, 2005). One strategy to help people experience
The concept of teaching people about pain biology
less pain and disability is to explain to people the biology
and physiology goes by various names, including
and physiology of their pain experience (Louw et al, 2011;
explain pain (Butler and Moseley, 2003; Moseley and
Moseley, Hodges, and Nicholas, 2004; Nijs and Van
Butler, 2015); pain neuroscience education (Nijs et al,
Houdenhove, 2009). Traditional physical therapy educa-
2011); pain biology education (Moseley, 2002); and
tion uses various anatomical, biomechanical, or pathoa-
therapeutic neuroscience education (PNE) (Louw,
natomical models to help people in pain understand why
Puentedura, Diener, and Peoples, 2015a; Zimney,
they hurt (Louw and Butler, 2011; Nijs et al, 2012). These
Louw, and Puentedura, 2014). For the purpose of this
models have proven limited efficacy in helping people
paper, it will be referred to as PNE, consistent with the
suffering from chronic pain with an inability to explain
author’s previous use of this term in various previous
persistent pain, spreading pain, allodynia, pain in absence
pain education studies (Louw, Diener, and Puentedura,
of injury or disease, immune responses or stress biology
2015; Louw, Puentedura, Diener, and Peoples, 2015a;
(Moseley, 2007a; Nijs et al, 2012). Furthermore, these
Zimney, Louw, and Puentedura, 2014). One of the first
models have been associated with inducing fear, anxiety
documented uses of neuroscience education for pain
and faulty beliefs, which all contribute to an increased
stems from zoologist turned physical therapist Louis
pain experience (Louw, Diener, and Puentedura, 2014;
Gifford at the International Association on the Study
Sloan and Walsh, 2010). It has been proposed that this
of Pain conference in Austria in 1999 (Gifford and
dichotomy of teaching people suffering from pain about
Muncey, 1999). Since 1999 and subsequently through
anatomy, versus pain science, may be a reason why

CONTACT Adriaan Louw, PT, PhD adriaan@ispinstitute.com International Spine and Pain Institute, P.O. Box 232, Story City, IA 50248, USA.
Color versions of one or more of the figures in this article can be found online at www.tandfonline.com/iptp.
© 2016 Taylor & Francis
386 A. LOUW ET AL.

the evidence-based medicine revolution, various scien- including PNE (Boissonnault and Ross, 2012; Louw
tists started exploring the efficacy of PNE, culminating and Butler, 2011; Sizer, Brismee, and Cook, 2007).
in various randomized controlled trials and two sys-
tematic reviews (Louw et al, 2011; Louw, Diener,
Skillful interview
Landers, and Puentedura, 2014; Meeus et al, 2010;
Moseley, 2002; Moseley, 2004; Moseley, Hodges, and Most outpatient physical therapists are trained in a
Nicholas, 2004; Ryan, Gray, Newton, and Granat, 2010; common interview strategy, in line with Maitland’s
Van Oosterwijck et al, 2011). The systematic review of five categories (Maitland, 1986): What brings you to
Louw et al. (2011) showed that for musculoskeletal therapy?; Where are the symptoms?; The behavior of
pain, PNE provides compelling evidence for reducing the symptoms?; The history of the disorder and then
pain, disability, pain catastrophization, and improved special questions. These are good questions and likely
physical movement (Louw et al, 2011). Regional, a place to start for the novice therapist to ensure a
national, and international physical therapy confer- comprehensive interview. For the more skilled PNE
ences are seeing an influx of presentations about the practitioner, these questions can be refined, aiming at
emerging pain neuroscience information. In contrast to understanding more about the patient’s experiences,
the science, there is a lack of consistent practical appli- suffering, and beliefs (Butler, 2000; Louw, Diener, and
cation of PNE into the “real world” of clinical practice Puentedura, 2014; Louw, Puentedura, and Mintken,
(Moseley and Butler, 2015; Nijs et al, 2011). 2012; Maitland, 1986). Questions fundamental to PNE
Key features of PNE have been identified in the would include: What do you think is going on with your
literature. Successful PNE is matched to the complexity back?; Why do you think you hurt?; What do you think
of each person’s individual pain experience (Moseley, should be done for your back? and Where do you see
2003b; Moseley, 2007a; Puentedura and Louw, 2012). It yourself in five years?
is dependent on developing a connection with a patient The aim of the interview is to develop an under-
through trust as well as through timing (Fuentes et al, standing of the person’s unique suffering and experi-
2014; Pinto et al, 2012). Important clinical elements ences, as well as discover what may motivate the patient
include thorough examinations (Gifford, 2014), paced in the goal-setting process (Butler, 2000; Gifford, 2014).
education (an active process) (Louw, Butler, Diener, Additionally, a good interview develops a therapeutic
and Puentedura, 2013), home exercise programs relationship (connection) with the patient, which leads
(HEP) (Moseley, 2002), movement, pacing, graded to trust, a critical component of PNE (Butler, 2000;
exposure, goal setting, and self-efficacy (Gifford, Gifford and Butler, 1997). During the interview, the
2014). To help guide clinicians with the application of clinician needs to listen for (and make a list of) issues
PNE in clinical practice, the aim of this paper is to the patient mentions that will need to be addressed
utilize various case studies (Louw, 2014; Louw, during PNE. The patient must be given adequate time
Puentedura, Diener, and Peoples, 2015a; Louw, to tell their story. Clinically, the skillful interview
Puentedura, and Mintken, 2012; Zimney, Louw, and usually lasts 20–25 minutes (Jones and Rivett, 2004).
Puentedura, 2014), case series (Louw, Diener, and
Puentedura, 2015), clinical trials (Louw, Diener,
Physical examination
Landers, and Puentedura, 2014) and perspectives
papers (Moseley and Butler, 2015; Nijs et al, 2011) to The physical examination needs to be thorough and
extract a proposed approach in an outpatient physical skillful to further rule out any significant pathology,
therapy clinic applying PNE to patients in chronic pain. alongside the interview findings (Jones and Rivett,
2004). Once significant tissue pathology can be clini-
cally excluded, the practitioner needs to focus on larger
Visit 1
global, functional movements (“low tech”; macro versus
One of the biggest fallacies associated with PNE is that micro) (Linton, 1998; Louw, Puentedura, and Mintken,
therapists “just talk” to patients. Those not familiar 2012). The results of the physical examination need to
with PNE propose that practitioners potentially miss be sensibly conveyed to the patient without inflated,
or minimize potential serious underlying pathological fear-inducing words (Louw, Diener, and Puentedura,
issues and thus put patients in harm. In line with 2014). It is proposed that this may be where many
current best-practice guidelines in musculoskeletal physical therapists falter. They might do a haphazard,
medicine, all therapists have to conduct a review of quick examination that may undermine the therapist–
systems, skilled interview, and thorough physical exam- patient relationship (Ndosi et al, 2016). The opposite
ination prior to embarking on any treatment plan, may occur with an overly focused examination on small
 PHYSIOTHERAPY THEORY AND PRACTICE 387

details, which may not be relevant (i.e., pelvic obliquity an increased pain experience (Louw, Butler, Diener,
and leg length discrepancy) in the face of a patient and Puentedura, 2012; Louw, Butler, Diener, and
struggling with widespread pain (Nijs et al, 2012). Puentedura, 2013). For PNE to work, a clinical envir-
“Low tech” tests and measures should include gross onment should aim to remove provocative images and
range of motion, a thorough neurological screening, language as means of educating people and all staff be
neurodynamic tests, and applicable special tests as updated on the “language of PNE.” Another part of
needed (Louw, Puentedura, and Mintken, 2012). “de-education” is sharing normative data with patients,
Clinically, it is often found that upon completion of thereby helping them understand that various “find-
both a thorough interview and skilled physical exam- ings” on medical tests and imaging may not correlate
ination, patients often get quite emotional with state- to pain (Nijs et al, 2012). For example, a patient may be
ments such as: “That was the most thorough medical extremely nervous to bend forward or return to work
examination I have had in years.” This develops con- since their magnetic resonance imaging (MRI) test
fidence and trust, key components of PNE, especially showed a “bulging” disc. Explaining to a patient, with
since people struggling with pain may have seen many compassion and empathy, that 40% of people with no
health care providers for their pain, some of whom low back pain (LBP) have similar “bulges” and yet
have dismissed or marginalized the patient’s pain continue on with their life, may in fact reduce their
experience. By enhancing the therapeutic relationship, fear of movement and catastrophization (Flynn, Smith,
the patient may be more receptive to treatment inter- and Chou, 2011). In turn, both fear-avoidance and pain
ventions, including PNE (Ndosi et al, 2016). The “low catastrophization are key elements predicting the suc-
tech” physical examination typically takes 10 minutes. cess of PNE (Louw et al, 2011).
Following the skillful interview and physical examina- The research currently shows PNE works best by using
tion, the therapist may determine that PNE is indicated. metaphors, examples, and pictures (Gallagher, McAuley,
Depending on the time available, the initial visit may and Moseley, 2013; Louw et al, 2011). An example is
allow for a brief introduction to PNE. An easy and whereby the body’s nervous system is metaphorically
receptive way for patients to be introduced to PNE is described as an alarm system (Louw, Puentedura,
by asking them: “Has anyone explained to you why you Diener, and Peoples, 2015a). The patient is made aware
(still) hurt?” (Louw, Puentedura, and Mintken, 2012). If of the sheer vasPNEss and complexity of the nervous
the patient indicates an interest in learning why they system: “There are more than 400 individual nerves that
hurt, an introductory metaphor, such as the alarm sys- combined make more than 45 miles of nerves within your
tem, is shared. The brief PNE session at first can vary in body, and they all are connected like a network of roads”
length based upon evaluation, time, patient learning (Louw, 2013). A picture of the human nervous system can
needs, and clinical reasoning, and will be built upon be shown to give the patient an appreciation for its com-
during subsequent sessions (paced education). plexity. A normal functioning nervous system is then
compared to an alarm system: When we step on a rusted
nail with our barefoot, we need to know about it, so we can
Therapeutic neuroscience education
take care of it. The nervous system, working like an alarm
Given the popularity of PNE, many clinicians may be system ramps up, sends a message to the brain and, upon
eager to delve into various pain metaphors to help taking action (taking the nail out, tetanus shot, bandage),
people gain an increased understanding of their pain. the alarm gradually calms down, ready to warn you of
There is, however, a fundamental part to PNE that is another nail in the future (Figure 1). This is a normal
often missed: “de-education” prior to “re-education” biophysiological process and occurs in every human
(O’Sullivan, Dankaerts, O’Sullivan, and O’Sullivan, being. The general example (nail in the foot) is then
2015). PNE involves a paradigm shift, contrasting very applied to the patient’s clinical presentation with further
prevalent biomedical models focusing on anatomy, bio- explanation in nonthreatening language that they likely
mechanics, and pathoanatomy (Moseley, 2007a; Nijs hurt some tissues when they had an injury or surgery and
et al, 2012). Words such as “tear,” “deterioration,” these tissues are or have gone through a normal healing
“herniation,” “wear and tear,” and “degeneration” are process over time. The nerves in the area, working like an
commonly associated with these models and instead of alarm system, also ramped up (like the foot example) telling
helping patients, in fact, increase fear and anxiety them to go seek treatment and care from a health care
(Greene, Appel, Reinert, and Palumbo, 2005; Morr provider.
et al, 2010). Accompanying these words are anatomical This story is used to convey the message that pain
charts, plastic joint models, and educational booklets may not necessarily be a true reflection of the health of
that perpetuate this message and overall contribute to their tissues, but includes various complex biologically
388 A. LOUW ET AL.

Figure 1. Metaphorical explanation of the nervous system as an alarm system during nociceptive activation (Images with permission
from Louw, 2013).

driven processes (as opposed to psychologically driven). Diener, and Peoples, 2015a; Moseley, 2004; Nijs et al,
This may help patients reconceptualize their pain 2011; Young, 2007).
experience (Gifford, 1998; Moseley, 2007a; Nijs et al, The introductory PNE metaphor allows clinicians an
2012) and aim to avoid patients falling into the mindset opportunity to explain and plan future sessions (e.g.,
of “you think my pain is in my head.” decreasing treatment frequency to allow patient more
The educational story continues with information time for processing of information) (Crabtree, Royeen,
regarding the fact that, in line with current epidemiol- and Mu, 2001) and continue to develop strategies to
ogy, in approximately one in four people, the alarm “calm down the alarm system.” While some research
system does not calm down after ramping up, but studies and initial clinical practice saw this delivery of
stays extra sensitive (Goldberg and McGee, 2011; PNE lasting upward of 1 hour, current clinical practice
Johannes et al, 2010). The extra-sensitive alarm system and research studies have shown that it can be deliv-
is a big reason why they are still experiencing pain. ered in 10–20 minutes depending on patient-specific
Before the onset of this pain, the alarm system had lots needs (Louw, Butler, Diener, and Puentedura, 2013;
of space (tolerance) for activities, but since being extra Louw, Diener, Landers, and Puentedura, 2014; Louw,
sensitive, there is less tolerance (Louw, Butler, Diener, Puentedura, Diener, and Peoples, 2015b; Zimney,
and Puentedura, 2013). Now, after only five minutes Louw, and Puentedura, 2014). This particular “alarm
of walking, the alarm system goes off. This metaphor system” metaphor can often be described to and dis-
of nerve sensitization gives the patient a different cussed with a patient in 10 minutes.
paradigm about why they still hurt (Louw, Butler, Practice and repetition may be essential in order to
Diener, and Puentedura, 2013). This provides a frame- develop a solid comfort level, clinical effectiveness, and
work for the therapist to discuss the issues surround- eventual mastery of PNE intervention (Nielsen, Keefe,
ing the injury that have likely caused her alarm system Bennell, and Jull, 2014; Nijs et al, 2011). Studies
to remain extra sensitive (yellow flags) such as failed acknowledge that each patient may require a different
treatments, stress and anxiety, different explanations starting point in their individualized PNE program
about her constant pain, and lost hope (Kendall, (Moseley, 2003b), yet it is also proposed that new
Linton, and Main, 1997). Next, the therapist is able clinicians benefit from moving through specific PNE
to devise a treatment plan designed to calm down the topics in predictable order as they are mastering the
extra-sensitive alarm system. Options include PNE, PNE patient language of nociceptive pathways, neu-
aerobic exercise, meditation, relaxation, manual ther- rons, synapses, action potentials, spinal inhibition and
apy, diaphragmatic breathing, goal setting, sleep facilitation, peripheral and central sensitization, and
hygiene, and more (Figure 2) (Louw, Puentedura, neuroplasticity (Louw and Puentedura, 2013). With
 PHYSIOTHERAPY THEORY AND PRACTICE 389

Figure 2. Graphic depiction of nerve sensitization as well as strategies to decrease nerve sensitization (Images with permission from
Louw, 2013).

consistent practice, therapists will be able to identify 2011; Pires, Cruz, and Caeiro, 2015), it is far superior in
and navigate around topics and starting points most reducing pain, compared to education alone. Clinically,
effective for each patient. Additional strategies to help after PNE, it is customary to either provide a patient
novice clinicians with clinical application of PNE are with four to five easy exercises to start doing at home,
the use of various measurement tools as educational or take their existing exercises and instruct them on the
tools. For example, questions in the pain neurophysiol- four to five you want them to focus on (Louw, 2014;
ogy questionnaire (Catley, O’Connell, and Moseley, Louw and Butler, 2011). By proving PNE first, the PNE
2013; Moseley, 2003c), fear-avoidance beliefs question- session could (and should) discuss patient perceptions
naire (Waddell et al, 1993), and central sensitization about exercise and challenge the reason and nature of
inventory (Neblett et al., 2013) can be used as helpful fears associated with exercise (Nijs et al, 2015). The
launching points to pose a question, followed by in- initial exercise session may only take five minutes.
depth pain neuroscience education of the particular The most common exercises are typically focused on
question. The accumulative time at the conclusion of large range-of-motion movements and/or neurody-
the interview (20–25 minutes), physical examination namics (Butler, 2000; Zimney, Louw, and Puentedura,
(10 minutes), and introductory PNE (10–15 minutes) 2014). Patients may also benefit from brief introduction
would be between 40 and 50 minutes. into relaxation or diaphragmatic breathing exercise
during this first session. The key is to introduce move-
ment that is perceived as safe and that also increases
Exercise
functional ability.
Unfortunately, many therapists who are minimally
familiar with PNE think of the strategy as only an
Home exercise program
educational and cognitive intervention. This is not the
case: various high-level randomized controlled trials Having the patient help themselves (self-efficacy) and
and both systematic reviews of PNE reported on var- having them take an active role in their recovery is
ious studies combining a movement/manual approach important (Gifford, 2014). The patient is now sent
with PNE (Louw et al, 2011). In fact, clinical trials have home with four simple tasks:
shown that PNE alone (education only) can benefit a
patient (Louw et al., 2011; Louw, Diener, Landers, and (1) Questions: The patient is asked to think, write
Puentedura, 2014; van Oosterwijck et al, 2013), but down, and bring back to the clinic at her next
when PNE is combined with either exercise or manual visit any questions she may have regarding her
therapy (Beltran-Alacreu, Lopez-de-Uralde-Villanueva, pain and the PNE material covered during ses-
Fernandez-Carnero, and La Touche, 2015; Louw et al, sion one. This will be part of every subsequent
390 A. LOUW ET AL.

session and aims to help remove doubt and Usually by visit three to four, most questions have been
develop a deep understanding of her pain answered. For patients who have no questions, the clin-
experience (Louw, 2014; Zimney, Louw, and ician is urged to ask them about their understanding of
Puentedura, 2014). their pain to determine to what extent they’ve undergone
(2) Exercise: The patient is encouraged to perform the (needed) deep learning process (Crabtree, Royeen, and
the key exercises to enhance movement as Mu, 2001; Hardcastle et al, 2015). The question and answer
clinically reasoned through the evaluation and segments also allow the opportunity for patients to expose
exercise portion of the encounter with focus on and challenge core beliefs. As a relationship develops,
breathing and relaxation while doing them. layers are often exposed, whereby a patient over time
(3) Aerobic exercise program: An aerobic exercise reveals a “true belief” or barrier to improvement. Given
program can have large psychosocial benefits the large-scale prevalence of the biomedical model, beliefs
that can promote self-efficacy and potentially regarding tissues are often exposed during these sessions.
contribute to the down-regulation of the sensi- For example, a patient may say: “I understand this pain
tized nervous system. For example, it has been stuff you’re talking about, but you don’t understand. . .I
shown that a 6-mile run stimulates endorphin have a bugling disc.” For the novice PNE-practitioner,
release that is equivalent to 10 mg of morphine this may seem devastating: They did not get it! For the
(Janal, Colt, Clark, and Glusman, 1984). This experienced clinician this is good – the patient exposed a
could include their exercise of choice (walking, true belief and without altering this for the better, therapy
riding bike, swimming) (Naugle, Fillingim, and in general, let alone PNE may not work (Vlaeyen and
Riley, 2012). The duration will be dependent Linton, 2000). In this scenario, normative data (de-educate
on the patient’s current level of activity and the and then re-educate) is once again key (O’Sullivan,
response to exercise. Start small and add to the Dankaerts, O’Sullivan, and O’Sullivan, 2015). In this sce-
duration over time in small increments. The nario, we once again reiterate “bulging” discs appear on
intention is to raise heart rate for the hypoal- MRIs of people with no LBP (Flynn, Smith, and Chou,
gesic effect of aerobic exercise (50% of maxi- 2011); various studies have shown that “bulging” discs
mum oxygen someone can use [VO2 max.] for reabsorb over time and typically resolved in a few months
10 minutes) (Hoffman, Shepanski, Mackenzie, (Masui et al., 2005; Yukawa et al., 1996); MRIs done supine
and Clifford, 2005). show “bulging” discs, whereas upright MRIs of the same
(4) Goals: The patient is asked to go home and person are devoid of the “bulging” disc (Miyazaki et al.,
return with a list of five goals that will then 2008); etc.
be refined and broken down into smaller pieces
(graded exposure and pacing). It is often
PNE (10 minutes)
famed: “If I could flip a switch, and get rid of
all your pain, what would you do again?” This At each session it is advised there is some quick review
often exposes deep desires of activities that, in of the previous PNE session’s information (recall) and
most cases, can be done again given pacing and then adding a new metaphor, example, and picture
time to get healthier. (Figure 4) (Gallagher, McAuley, and Moseley, 2013;
Louw et al, 2011). Various pain metaphors chosen to
coincide with a specific issue the patient may have are
chosen. For example, the metaphor discussing “nerve
Visits number 2, 3, 4 . . .
sensors” as a means to explain ion channel contribu-
Once the initial plan of care has been set in motion, tions to sensitization is used for people who experience
subsequent therapy sessions would last approximately increased pain when they are stressed, while “nosy
30–40 minutes and include the following focuses. neighbors” are used to biologically explain spreading
pain associated with peripheral and central sensitiza-
tion (Louw, 2013). The average time of these stories are
Questions and answers
10–12 minutes, leaving the remaining time for tradi-
Any questions are answered from a PNE perspective. tional therapy interventions (Louw, 2014; Louw,
Research describing deep learning theory, conceptual Puentedura, and Mintken, 2012; Zimney, Louw, and
change, and behavior change indicates that patients who Puentedura, 2014). The teaching can sometimes occur
ask a lot of questions are often the ones who recover the while the patient is exercising in the clinic, such as
best (Prochaska and Velicer, 1998; Sandberg and Barnard, riding a stationary bike, to maximize efficient use of
1997). They are engaged, inquisitive, and actively learning. clinic time.
 PHYSIOTHERAPY THEORY AND PRACTICE 391

Goals (five minutes)

A quick review, update and changes on goals, pacing
and graded exposure is then employed to ensure the
patient continues with goal-motivated behavior for
therapy (Gifford, 2014).

“Traditional therapy”
The remaining 15–20 minutes is used to focus on a
variety of treatments the therapists may clinically rea-
Figure 3. Progression over time related to pain science con-
son as important. This can include manual therapy, soft
trasting pain experience and functional levels (Adapted from
tissue treatments, relaxation techniques, diaphragmatic Gifford, 2014 by Schmidt S – with permission).
breathing, modalities, neurodynamic exercises,
stretches, and conditioning (Louw and Butler, 2011;
Louw and Puentedura, 2013).
Clinically, once patients are engaged in an exercise
program (or demonstrate a deeper understanding of
their pain), develop various strategies to help them-
selves (sleep, relaxation, stretches) and are pacing
themselves to their goals, they see an opportunity to
continue their care at home. Patients may confront
the physical therapist with “I could do this at home,
couldn’t I?” This culmination of the PNE process,
intertwined in pacing, graded exposure, goal setting,
and self-efficacy is likely the pinnacle of PNE out-
comes – true behavior change. For the clinicians, it Figure 4. Paced therapeutic neuroscience education.
implies less focus on pain and more focus on func-
tion. The ultimate goal with behavior change in a
patient’s progress should be “despite the pain”; having imbedded in cognitive, motivational, educationa,l and
someone accomplish more (Louw, Diener, Landers, various psychological theories and principles (Gifford,
and Puentedura, 2014; Moseley, 2007a). One-year 2014; Moseley and Butler, 2015).
follow-up studies utilizing PNE shows a steady
decrease is pain over time, while functional levels
(per outcome measures) increase (Figure 3). It is Trust
within the framework of “despite the pain” that People in pain often undergo numerous different tests
patients are focused on their functional levels, and treatments and are furthermore exposed to var-
achievements, and goals, rather than pain. ious opinions (Louw, 2015). With these approaches
Clinically, however, the recovery process is not lin- come anticipation and expectation of success and if,
ear. Given the complexities of pain in regard to central over time, these are not met, it will add to the
and peripheral sensitization, neuroplasticity, ion chan- patients’ pain experience (Toyone et al, 2005). These
nel expressions, emotions, etc., pain experiences fluc- experiences may often leave patients disillusioned,
tuate (Nijs et al, 2011). Pain by its nature is inconsistent frustrated, and less trusting of the medical profession.
(Gifford, 2014). In line with these fluctuations, function To date, therapy has been heavily focusing on biome-
will fluctuate. It is also proposed that these fluctuations dical models to explain pain to patients, which have
contain potential opportunities for patients to regress shown to have limited efficacy, but likely contribute
and strengthen the argument for continued PNE along to the patient’s overall erosion of trust in the medical
the path of recovery (Figure 4). community (Nijs et al, 2012). PNE embraces various
psychological issues associated with pain. Even more
so, PNE intertwines psychosocial aspects of pain with
More than “JUST” PNE
the biological and physiological paradigms of pain
This layout of a “typical” PNE program has many small (Gifford, 1998). This merger is part of the much-
nuances not to be overlooked. These nuances are needed biopsychosocial aspects of treating people in
392 A. LOUW ET AL.

pain and thus requires time spent with a patient; about the health of tissues may be quite beneficial
thorough interviewing and physical touch, all of (Gifford, 2014; Louw and Butler, 2011). For chronic
which have been highly ranked by patients seeing pain, however, these traditional models may not only
care for pain (Robinson and King, 2011; Verbeek, be limited in their efficacy, but also induce fear
Sengers, Riemens, and Haafkens, 2004). (Greene, Appel, Reinert, and Palumbo, 2005; Louw,
Diener, and Puentedura, 2014). PNE as an emerging
science teaches patients how pain works from a bio-
Compliance
logical and physiological perspective. PNE research is
Various studies examining compliance have shown that dominated with randomized controlled trials and sys-
patients perform better when they have specified para- tematic reviews, all aiming to explore the efficacy of
meters or boundaries (Bollini et al, 2006; Roter et al, PNE (Louw et al, 2011; Louw, Diener, Landers, and
1998; Wong and Wong, 1985). The patient is respon- Puentedura, 2014; Moseley, 2002; Moseley, Hodges,
sible and must take an active role in his or her own care and Nicholas, 2004). Writing a perspectives paper on
(Roter et al, 1998). A verbal contract is set up to lay out the clinical application of PNE is far more daunting
the plan of care associated with being timely for and than a report of, or review of, the evidence for PNE.
attending appointments as well as completion of writ- The aforementioned proposal of clinical application of
ten homework (Louw, 2014; Moseley, 2006). The writ- PNE is a combination of previous proposals (Nijs
ten homework typically constitutes an exercise log, et al, 2011), past experiences (Butler, 2000; Gifford,
specific areas to record home exercises, progress toward 2014), summary of educational delivery methods (Nijs
goals, sleep hours, and space for journaling. It is recom- et al, 2011), various case studies reporting on clinical
mended the diary does not focus or emphasize negative utilization of PNE (Louw, 2014; Louw, Puentedura,
aspects, that is, pain ratings. Keeping patients compli- and Mintken, 2012; Puentedura, Brooksby, Wallmann,
ant aids in the overall execution of the PNE program and Landers, 2009; Zimney, Louw, and Puentedura,
(Louw, 2014; Moseley, 2006). 2014) and textbooks written by authors researching
PNE (Butler and Moseley, 2003; Gifford, 2014; Louw
and Puentedura, 2013; Moseley, 2007b). There is no
Environment
doubt that a perspectives paper such as this will
PNE is not only teaching patients about the neu- receive criticism, and needs to be recognized for the
roscience of pain, but also a powerful “undoing” of level of evidence it provides and its role in evidence-
previous dominant biomedical models (O’Sullivan, based medicine (Burns, Rohrich, and Chung, 2011).
Dankaerts, O’Sullivan, and O’Sullivan, 2015). First, its aim is to use the current evidence and
Dominant biomedical models, which have been published literature to develop a possible clinical lay-
shown to potentially harm patients (Louw, Diener, out of a proposed PNE program. Second, the paper
and Puentedura, 2014; Nijs et al, 2012), also present aims to allow clinicians, limited by the reality of
themselves in daily clinical practice. Visible anatomical clinical practice (time, frequency, cost, and accessibil-
pictures and clinical models can undermine the efficacy ity) to have a blueprint that can be personalized and
of a PNE program. In contrast, visual cues using adapted to a specific clinical practice. Third, and
powerful images associated with PNE can be displayed likely most important, the paper should stimulate
as a means to add to a deep learning process and send a discussion and fuel research. The efficacy of PNE is
unified message to patients embracing PNE. ever increasing, along with its prevalence at regional,
Additionally, support staff (i.e., receptionists) can also national, and international conferences, yet little is
contribute to an overall PNE message with proper known about clinical application. Scientists are urged
exposure of a pain science approach. Receptionists to examine this paper and from it design research
greeting patients warmly, showing empathy, avoiding proposals to answer much-needed clinical questions.
threatening language, and asking patients about their We are already seeing such work, including applica-
progress rather over-focusing on pain can all reinforce tion of PNE in acute conditions (Louw, Diener,
a PNE approach. Landers, and Puentedura, 2014; Zimney, Louw, and
Puentedura, 2014), abbreviated PNE (Louw,
Puentedura, and Mintken, 2012), group versus one-
Conclusion
on-one verbal education (Moseley, 2003a), telehealth
Patients are interested in pain (Louw et al., 2009). In and PNE (Louw, 2014), aquatic therapy and PNE
acute injuries or immediate postoperative periods, (Pires, Cruz, and Caeiro, 2015), dry needling and
traditional biomedical models teaching patients PNE (Tellez-Garcia et al, 2015), and more. But there
 PHYSIOTHERAPY THEORY AND PRACTICE 393

is more, including predictors of success with PNE, Hardcastle SJ, Hancox J, Hattar A, Maxwell-Smith C,
optimal timing, and duration, etc. The ultimate Thogersen-Ntoumani C, Hagger MS 2015 Motivating the
expression of PNE’s efficacy is clinical application unmotivated: How can health behavior be changed in
those unwilling to change? Frontiers in Psychology 6: 835.
and helping people who suffer from persistent pain. Hoffman MD, Shepanski MA, Mackenzie SP, Clifford PS
2005 Experimentally induced pain perception is acutely
reduced by aerobic exercise in people with chronic low
References back pain. Journal of Rehabilitation Research and
Development 42: 183–190.
Beltran-Alacreu H, Lopez-de-Uralde-Villanueva I, Fernandez-
Janal MN, Colt EW, Clark WC, Glusman M 1984 Pain
Carnero J, La Touche R 2015 Manual therapy, therapeutic
sensitivity, mood and plasma endocrine levels in man
patient education, and therapeutic exercise, an effective
following long-distance running: Effects of naloxone.
multimodal treatment of nonspecific chronic neck pain: A
Pain 19: 13–25.
randomized controlled trial. American Journal of Physical
Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH
Medicine and Rehabilitation 94 (10 Suppl 1): 887–897.
2010 The prevalence of chronic pain in United States
Boissonnault WG, Ross MD 2012 Physical therapists refer-
adults: Results of an Internet-based survey. Journal of
ring patients to physicians: A review of case reports and
Pain 11: 1230–1239.
series. Journal of Orthopaedic and Sports Physical Therapy
Jones MA, Rivett DA 2004 Clinical Reasoning for Manual
42: 446–454.
Therapists. Edinburgh, Butterworth Heinemann.
Bollini P, Pampallona S, Kupelnick B, Tibaldi G, Munizza C
Kendall NA, Linton SJ, Main CJ 1997 Guide to assessing
2006 Improving compliance in depression: a systematic
psychosocial yellow flags in acute low back pain: Risk
review of narrative reviews. Journal of Clinical Pharmacy
factors for long term disability and work loss.
and Therapeutics 31: 253–260.
Wellington, Accident Rehabilitation and Compensation
Burns PB, Rohrich RJ, Chung KC 2011 The levels of evidence
Insurance Corporation of New Zealand and the National
and their role in evidence-based medicine. Plastic and
Health Committee.
Reconstructive Surgery 128: 305–310.
Linton SJ 1998 The socioeconomic impact of chronic back
Butler DS 2000 The Sensitive Nervous System. Adelaide,
pain: is anyone benefiting? Pain 75: 163–168.
Noigroup.
Louw A 2013 Why Do I Hurt? A Neuroscience Approach to
Butler DS, Moseley LS 2003 Explain Pain. Adelaide, NOI
Pain. Minneapolis, MN, OPTP.
Publications.
Louw A 2014 Therapeutic neuroscience education via e-mail: A
Catley MJ, O’Connell NE, Moseley GL 2013 How good is the
case report. Physiotherapy Theory and Practice 30: 588–596.
neurophysiology of pain questionnaire? A Rasch analysis
Louw A 2015 Treating the brain in chronic pain. In:
of psychometric properties. Journal of Pain 14: 818–827.
Fernandez de las Penas C, Cleland J, Dommerholt J (eds)
Crabtree JL, Royeen CB, Mu K 2001 The effects of learning
Manual Therapy for Musculoskeletal Pain Syndromes
through discussion in a course in occupational therapy: A
(Vol. 1). London, Churchill Livingston.
search for deep learning. Journal of Allied Health 30: 243–
Louw A, Butler DS 2011 Chronic pain. In: Brotzman SB,
247.
Manske RC (eds) Clinical Orthopaedic Rehabilitation,
Flynn TW, Smith B, Chou R 2011 Appropriate use of diag-
3rd edn. Philadelphia, PA, Elsevier.
nostic imaging in low back pain: A reminder that unne-
Louw A, Butler DS, Diener I, Puentedura EJ 2012
cessary imaging may do as much harm as good. Journal of
Preoperative education for lumbar radiculopathy: A
Orthopaedic and Sports Physical Therapy 41: 838–846.
Survey of US spine surgeons. International Journal of
Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B,
Spine Surgery 6: 130–139.
Warren S, Rashiq S, Magee D J, Gross DP 2014 Enhanced
Louw A, Butler DS, Diener I, Puentedura EJ 2013 Development
therapeutic alliance modulates pain intensity and muscle pain
of a preoperative neuroscience educational program for
sensitivity in patients with chronic low back pain: An experi-
patients with lumbar radiculopathy. American Journal of
mental controlled study. Physical Therapy 94: 477–489.
Physical Medicine and Rehabilitation 92: 446–452.
Gallagher L, McAuley J, Moseley GL 2013 A randomized-
Louw A, Diener I, Butler DS, Puentedura EJ 2011 The effect
controlled trial of using a book of metaphors to reconcep-
of neuroscience education on pain, disability, anxiety, and
tualize pain and decrease catastrophizing in people with
stress in chronic musculoskeletal pain. Archives of Physical
chronic pain. Clinical Journal of Pain 29: 20–25.
Medicine and Rehabilitation 92: 2041–2056.
Gifford LS 1998 Pain, the tissues and the nervous system.
Louw A, Diener I, Butler DS, Puentedura EJ 2013
Physiotherapy 84: 27–33.
Preoperative education addressing postoperative pain in
Gifford LS 2014 Aches and Pain. Cornwall, Wordpress.
total joint arthroplasty: Review of content and educational
Gifford LS, Butler DS 1997 The integration of pain sciences
delivery methods. Physiotherapy Theory and Practice 29:
into clinical practice. Journal of Hand Therapy 10: 86–95.
175–194.
Gifford LS, Muncey H 1999 Explaining Pain to Patients.
Louw A, Diener I, Landers MR, Puentedura EJ 2014
Paper presented at the International Association on the
Preoperative pain neuroscience education for lumbar radi-
Study of Pain, Vienna, Austria.
culopathy: A multicenter randomized controlled trial with
Goldberg DS, McGee S J 2011 Pain as a global public health
1-year follow-up. Spine 39: 1449–1457.
priority. BMC Public Health 11: 770.
Louw A, Diener I, Puentedura E 2014 Comparison of termi-
Greene DL, Appel AJ, Reinert SE, Palumbo M A 2005
nology in patient education booklets for lumbar surgery.
Lumbar disc herniation: Evaluation of information on the
International Journal of Health Sciences 2: 47–56.
internet. Spine 30: 826–829.
394 A. LOUW ET AL.

Louw A, Diener I, Puentedura EJ 2015 The short term effects Moseley GL 2007a Reconceptualising pain according to mod-
of preoperative neuroscience education for lumbar radicu- ern pain sciences. Physical Therapy Reviews 12: 169–178.
lopathy: A case series. International Journal of Spine Moseley GL 2007b Painful Yarns. Minneapolis, MN, OPTP.
Surgery 9: 11. Moseley GL, Butler DS 2015 Fifteen years of explaining pain:
Louw A, Louw Q, Crous LC 2009 Preoperative education for The past, present, and future. Journal of Pain 16: 807–813.
lumbar surgery for radiculopathy. South African Journal of Moseley GL, Hodges PW, Nicholas MK 2004 A randomized
Physiotherapy 65(2): 3–8. controlled trial of intensive neurophysiology education in
Louw A, Puentedura EJ 2013 Therapeutic Neuroscience chronic low back pain. Clinical Journal of Pain 20: 324–330.
Education (Vol. 1). Minneapolis, MN, OPTP. Naugle KM, Fillingim RB, Riley JL 2012 A meta-analytic
Louw A, Puentedura EJ, Diener I, Peoples RC 2015a review of the hypoalgesic effects of exercise. Journal of
Preoperative therapeutic neuroscience education for lum- Pain 13: 1139–1150.
bar radiculopathy: A single-case fMRI report. Ndosi M, Johnson D, Young T, Hardware B, Hill J, Hale C,
Physiotherapy Theory and Practice. Maxwell J, Roussou E, Adebajo A 2016 Effects of needs-
Louw A, Puentedura EJ, Diener I, Peoples RR 2015b based patient education on self-efficacy and health out-
Preoperative therapeutic neuroscience education for lum- comes in people with rheumatoid arthritis: A multicentre,
bar radiculopathy: A single-case fMRI report. single blind, randomised controlled trial. Annals of the
Physiotherapy Theory and Practice 31(7): 496–508. Rheumatic Diseases 75: 1126–1132.
Louw A, Puentedura EJ, Mintken P 2012 Use of an abbre- Neblett R, Cohen H, Choi Y, Hartzell MM, Williams M,
viated neuroscience education approach in the treatment Mayer TG, Gatchel RJ 2013 The Central Sensitization
of chronic low back pain: A case report. Physiotherapy Inventory (CSI): Establishing clinically significant values
Theory and Practice 28: 50–62. for identifying central sensitivity syndromes in an outpa-
Maitland GD 1986 Vertebral Manipulation, 6th edn. London, tient chronic pain sample. Journal of Pain 14: 438–445.
Butterworths. Nielsen M, Keefe FJ, Bennell K, Jull GA 2014 Physical thera-
Masui T, Yukawa Y, Nakamura S, Kajino G, Matsubara Y, pist-delivered cognitive-behavioral therapy: a qualitative
Kato F, Ishiguro N 2005 Natural history of patients with study of physical therapists’ perceptions and experiences.
lumbar disc herniation observed by magnetic resonance Physical therapy 94: 197–209.
imaging for minimum 7 years. Journal of Spinal Disorders Nijs J, Lluch Girbes E, Lundberg M, Malfliet A, Sterling M
and Techniques 18: 121–126. 2015 Exercise therapy for chronic musculoskeletal pain:
Meeus M, Nijs J, Van Oosterwijck J, Van Alsenoy V, Truijen Innovation by altering pain memories. Manual Therapy
S 2010 Pain physiology education improves pain beliefs in 20: 216–220.
patients with chronic fatigue syndrome compared with Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum
pacing and self-management education: A double-blind M, Meeus M 2011 How to explain central sensitization to
randomized controlled trial. Archives of Physical patients with ‘unexplained’ chronic musculoskeletal pain:
Medicine and Rehabilitation 91: 1153–1159. Practice guidelines. Manual Therapy 16: 413–418.
Miyazaki M, Hong SW, Yoon SH, Zou J, Tow B, Alanay A, Nijs J, Roussel N, Paul van Wilgen C, Koke A, Smeets R 2013
Abitbol JJ, Wang JC 2008 Kinematic analysis of the rela- Thinking beyond muscles and joints: Therapists’ and
tionship between the grade of disc degeneration and patients’ attitudes and beliefs regarding chronic musculos-
motion unit of the cervical spine. Spine 33: 187–193. keletal pain are key to applying effective treatment. Manual
Morr S, Shanti N, Carrer A, Kubeck J, Gerling MC 2010 Therapy 18: 96–102.
Quality of information concerning cervical disc herniation Nijs J, Van Houdenhove B 2009 From acute musculoskeletal
on the Internet. Spine Journal 10: 350–354. pain to chronic widespread pain and fibromyalgia:
Moseley GL 2002 Combined physiotherapy and education is Application of pain neurophysiology in manual therapy
efficacious for chronic low back pain. Australian Journal of practice. Manual Therapy 14: 3–12.
Physiotherapy 48: 297–302. O’Sullivan K, Dankaerts W, O’Sullivan L, O’Sullivan P B 2015
Moseley GL 2003a Joining forces - combining cognition- Cognitive functional therapy for disabling nonspecific
targeted motor control training with group or individual chronic low back pain: Multiple case-cohort study.
pain physiology education: a successful treatment for Physical Therapy 95: 1478–1488.
chronic low back pain. Journal of Manual and Pinto RZ, Ferreira ML, Oliveira VC, Franco MR, Adams R,
Manipulative Therapy 11: 88–94. Maher CG, Ferreira PH 2012 Patient-centred communica-
Moseley GL 2003b A pain neuromatrix approach to patients tion is associated with positive therapeutic alliance: A
with chronic pain. Manual Therapy 8: 130–140. systematic review. Journal of physiotherapy 58: 77–87.
Moseley GL 2003c Unraveling the barriers to reconceptualiza- Pires D, Cruz EB, Caeiro C 2015 Aquatic exercise and pain
tion of the problem in chronic pain: the actual and perceived neurophysiology education versus aquatic exercise alone
ability of patients and health professionals to understand the for patients with chronic low back pain: A randomized
neurophysiology. Journal of Pain 4: 184–189. controlled trial. Clinical Rehabilitation 29: 538–547.
Moseley GL 2004 Evidence for a direct relationship between Prochaska JO, Velicer WF 1998 Behavior change: The trans-
cognitive and physical change during an education inter- theoretical model of health behaviour change. American
vention in people with chronic low back pain. European Journal of Health Promotion 12: 38–48.
Journal of Pain 8: 39–45. Puentedura EJ, Brooksby CL, Wallmann HW, Landers MR
Moseley GL 2006 Do training diaries affect and reflect adher- 2009 Rehabilitation following lumbosacral percutaneous
ence to home programs? Arthritis and Rheumatism 55: nucleoplasty: A case report. Journal of Orthopaedic and
662–664. Sports Physical Therapy 40: 214–224.
 PHYSIOTHERAPY THEORY AND PRACTICE 395

Puentedura EJ, Louw A 2012 A neuroscience approach to fibromyalgia: a double-blind randomized controlled trial.
managing athletes with low back pain. Physical Therapy in Clinical Journal of Pain 29: 873–882.
Sport 13: 123–133. Van Oosterwijck J, Nijs J, Meeus M, Truijen S, Craps J, Van
Robinson V, King R 2011 ‘Explain Pain’ as part of a pain den Keybus N,Paul L 2011 Pain neurophysiology educa-
management service improves patient’s understanding of tion improves cognitions, pain thresholds, and movement
the neurophysiology of chronic pain. Journal of the performance in people with chronic whiplash: a pilot
Physiotherapy Pain Association 32: 27–30. study. Journal of Rehabilitation Research and
Roter DL, Hall JA, Merisca R, Nordstrom B, Cretin D, Development 48: 43–58.
Svarstad B 1998 Effectiveness of interventions to improve Verbeek J, Sengers MJ, Riemens L, Haafkens J 2004 Patient
patient compliance: A meta-analysis. Medical Care 36: expectations of treatment for back pain: a systematic
1138–1161. review of qualitative and quantitative studies. Spine 29:
Ryan CG, Gray HG, Newton M, Granat MH 2010 Pain 2309–2318.
biology education and exercise classes compared to pain Vlaeyen JW, Linton SJ 2000 Fear-avoidance and its conse-
biology education alone for individuals with chronic low quences in chronic musculoskeletal pain: a state of the art.
back pain: A pilot randomised controlled trial. Manual Pain 85: 317–322.
Therapy 15: 382–387. Waddell G, Newton M, Henderson I, Somerville D, Main CJ
Sandberg J, Barnard Y 1997 Deep learning is difficult. 1993 A fear-avoidance beliefs questionnaire (FABQ) and
Instructional Science 25: 15–36. the role of fear avoidance beliefs in chronic low back pain
Sizer PS, Brismee JM, Cook C 2007 Medical screening for red and disability. Pain 52: 157–168.
flags in the diagnosis and management of musculoskeletal Wall PD, Melzack R 2005 Textbook of Pain, 5th edn.
spine pain. Pain Practice 7: 53–71. London, Elsevier.
Sloan TJ, Walsh DA 2010 Explanatory and diagnostic labels Wong J, Wong S 1985 A randomized controlled trial of a new
and perceived prognosis in chronic low back pain. Spine approach to preoperative teaching and patient compliance.
35: E1120–1125. International Journal of Nursing Studies 22: 105–115.
Tellez-Garcia M, de-la-Llave-Rincon AI, Salom-Moreno J, Young SN 2007 How to increase serotonin in the human
Palacios-Cena M, Ortega-Santiago R, Fernandez-de-Las- brain without drugs. Journal of Psychiatry and
Penas C 2015 Neuroscience education in addition to trig- Neuroscience 32: 394–399.
ger point dry needling for the management of patients Yukawa Y, Kato F, Matsubara Y, Kajino G, Nakamura S,
with mechanical chronic low back pain: A preliminary Nitta H 1996 Serial magnetic resonance imaging follow-
clinical trial. Journal of Bodywork and Movement up study of lumbar disc herniation conservatively treated
Therapies 19: 464–472. for average 30 months: Relation between reduction of
Toyone T, Tanaka T, Kato D, Kaneyama R, Otsuka M 2005 herniation and degeneration of disc. Journal of Spinal
Patients’ expectations and satisfaction in lumbar spine Disorders 9: 251–256.
surgery. Spine 30: 2689–2694. Zimney K, Louw A, Puentedura E J 2014 Use of Therapeutic
Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal Neuroscience Education to address psychosocial factors
A, Lambrecht L, Nijs J 2013 Pain physiology education associated with acute low back pain: A case report.
improves health status and endogenous pain inhibition in Physiotherapy Theory and Practice 30: 202–209.
Copyright of Physiotherapy Theory & Practice is the property of Taylor & Francis Ltd and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.